Background: On an international level older patients with chronic diseases are expected to increase. To meet their subsequent upcoming health-care needs there is a trend towards delivering care within the Primary Health Care setting and in home-based care. Management continuity with shared care plans is especially important to secure a continued care for older patients with comorbidity. To achieve a safe and continued home-based care after hospital discharge it is, in Sweden, mandatory to conduct a shared care plan, named Coordinated Individual Plan (CIP). A thoroughly planned CIP upon discharge increases the probability of an optimal and safe home-based care. Thus, this study aimed to explore Swedish registered nurses in home-based care experiences of working with Coordinated Individual Plans established for older patients after hospital discharge.

Methods: Data were collected using interviews with 10 registered nurses (RNs) in ten municipalities in the southern parts of Sweden. The municipalities represented a diversity in socioeconomics and urban-rural environments. The interviews were audiotaped, transcribed, and analysed using inductive content analysis. The qualitive method and reporting of results adhere to the Consolidated criteria for reporting qualitative studies (COREQ).  

Results: The analysis reflected that the RNs conveyed information about the patients needs to involved professionals before, during and after a CIP meeting. In addition, the RNs found it beneficial to have a medical plan in the CIP with a formally documented statement about the level of care for the patient. This was particularly appreciated when assessing a patient with deteriorating health condition who was unknown to the RN.

Conclusions: Our findings implied that focus was on medical diagnoses in CIP and less focus was given to the other professionals’ perspectives. In addition, the RNs described interprofessional collaboration difficulties before, during and after the CIP-meeting resulting in possible safety risks and readmission of the patient to the inpatient care. To achieve safe care and management continuity for patients in home-based care, it is suggested that complementary interventions to CIP, to promote interprofessional collaboration are considered in future research.